Director of Patient Safety and Quality & Risk Management

    December 5, 2022
    Tucson Region, Arizona
    Job Type


    Our client, a 100-bed hospital located in Tucson region, has a need for a Director of Patient Safety and Quality & Risk Management to join their team.


    $113,574.00 to $164,555.00




    $10,000.00 Sign On Bonus and relocation assistance with a minimum two years’ experience in Leadership in Quality. Two-year commitment is required. Former CVMC employees who left within one year not eligible for sign on bonus and relocation***




    Bachelor’s degree in nursing preferred, associate degree in nursing required

    Arizona Registered Nurse Required

    Minimum 3 years leadership experience


    Job Description

    Position Summary/Description:

    The Patient Safety and Quality works collaboratively with the senior leadership team, department directors, and medical staff to lead, develop and oversee a best-in-class hospital quality and safety program and to ensure regulatory compliance and accreditation.


    Participate in hospital activities as a member of the leadership team.

    Role model for compliant behavior consistent with the mission, vision, and values of LifePoint and the hospital.

    Oversee the direct operations of the Quality Department, including Risk, Infection Prevention, Patient Satisfaction and Trauma Coordination.

    Motivate, mentor, develop and evaluate staff in the Quality Department.

    Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence.

    Regularly communicate quality, performance improvement, regulatory compliance and safety activities to the medical staff, executive team, hospital leaders and Board of Trustees

    Lead the development of hospital policies and procedures related to quality improvement and patient safety.

    Develop long-range goals, annual objectives and strategies for areas of responsibility.

    Aid in the organization and implementation of the hospital and Board safety and quality committees and key strategic patient safety and quality initiatives

    Quality Assurance and Performance Improvement

    In collaboration with hospital leadership, medical staff, and the Hospital Service Center (HSC) participate in the development, monitoring, reporting and improvement of activities related to hospital quality and safety in order to achieve organizational targets and goals.

    Collaborate with hospital and physician leaders to envision, develop, and implement the organization’s comprehensive safety and quality program.

    Oversees reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration, and recognition programs. (Including reports for Medical Staff Committees, Board of Trustees, MOR, etc)

    Participates in root cause analyses and failure modes and effects analyses and debriefings.

    Takes a lead role in the LeapFrog Survey, Culture of Safety Survey, and implementation/monitoring of the National Quality Program.

    Ensures timely submission of Quality data to the HSC, LeapFrog, Quality Net, HIIN, NHSN, National Quality Program and other required agencies.

    Advanced Process Improvement Knowledge and Experience

    Directs and coordinates accreditation strategies to ensure compliance with State, Joint Commission and Medicare Conditions of Participation.

    In collaboration with Compliance, Risk Management, and Legal, oversee the investigation and reporting of events as required by regulatory agencies and serves as a physician liaison in PI efforts related to medical safety.

    Coordinate and oversee data collection and analysis, reporting, improvement activities and follow-up related to serious safety events via the Patient Safety Organization.

    Devise, implement and coordinate a plan for JC tracer activities.


    Position Requirements:

    Complies with legal, hospital and departmental policies, procedures and position requirements. Must have an active RN License

    (AZ within 60 days of hire). Must have an associate degree in Nursing, bachelor degree preferred.

    Completed in 2015, our facility offers:

    Emergency Services with a Level III Trauma Unit

    Women and Children’s Services

    Birthing Suites

    Level I Nursery

    Bone & Joint Institute Center of Excellence for Total Joint Replacement

    Intensive / Progressive / Acute Care

    Cardiac Catheterization Lab

    Surgical Services / Outpatient Surgery Center

    Adult Psychiatric Unit

    Advanced Diagnostic Imaging to include 3D Mammography

    Laboratory Services

    Rehabilitation Services

    Two Helicopter Pads

    Wound Care

    Center of Excellence for Total Joint Replacement

    Pink Ribbon Facility Recognized For Excellence in Breast Health

    American College of Radiology Accredited Facility

    More than 7,600 annual patient visits

    800 births each year

    28,000 annual emergency room visits

    Over 300 annual total joint replacements

    3,100 annual surgeries

    375,000 tests performed annually in our accredited full-service


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